Gijs Bleijenberg retires

First Simon Wessely leaves the field (again), now the Dutch CBT & Biopsychosocial supremo will retire this Friday. I suspect there are many researchers left behind who will eagerly continue their work.

Prof. Gijs Bleijenberg, the clinical psychologist who introduced cognitive behavioral therapy for chronic fatigue syndrome, is stepping down as chair at the UMC. He is retiring. In his farewell speech, he explains why not all types of fatigue are the same. And what they have in common.

Chronic fatigue is a disaster not only for the individual, but also a major social problem. Besides the people who suffer from CFS, experts estimate around 80,000, there are also others who are dealing with extreme fatigue. For example, people who have been treated for cancer or people with chronic illness. Many chronic diseases are known to be associated with severe fatigue. According to Bleijenberg this means that in the Netherlands at least half a million people have chronic fatigue.

For most of his working life Bleijenberg has been involved with chronic fatigue and its treatment. In the Netherlands he developed a form of cognitive behavioral therapy (CBT) which is effective in people with chronic fatigue syndrome. Later it appeared that other people with chronic fatigue will benefit from this form of therapy. Together with his colleagues he developed effective forms of CBT for cancer-related fatigue, chronic fatigue in MS patients and in neuromuscular diseases.

Bleijenberg: What amazes is that there is so little money is allocated to the national introduction of these effective therapies. "There is a lot of money spent on proper investigation into the treatment of fatigue," he says in his farewell speech, "that has produced good treatment (Google translate: cures). These treatments can now be performed by trained behavioral therapists, but there is hardly any money available for their training. The additional behavioral training would be a great way to save money: it would relieve the burden of fatigue and reduce reliance on expensive equipment. "

In his farewell speech, Bleijenberg discussed the mechanism of action of CBT. This is much the same for the various groups with severe fatigue. CBT is effective because it changes the patient's attitudes and thinking about fatigue. Changes in attitudes about physical activity and exercise also have an effect on decreasing fatigue.

Graded exercise therapy (GET), based on gradually increasing physical activity, is also effective for chronic fatigue syndrome. "But here it appears the move [exercise?] itself is not the operative factor," said Bleijenberg. "Even with this therapy, the beliefs about exercise change will be effective."

However, different chronic fatigue states are not the same. The Donders found with the Nijmegen Research Centre Chronic Fatigue, that people with CFS have less gray matter in their brains than healthy people. After treatment with CBT, the volume of gray matter increases. On the other hand, in case of fatigue after cancer, there was no decrease in gray matter, and can be seen therefore, do not increase in gray matter after the treatment. This indicates that CFS is different biologically than cancer-related fatigue.

Something similar can be seen at the level of the hormone cortisol in saliva. In CFS, this content is relatively low and it increases as the cognitive-behavioral starts better. In people who have had cancer, there is no difference in cortisol levels between fatigued and non-fatigued.

The many faces of fatigue
The circumstances preceding the fatigue and the factors that maintain fatigue are differenct between patient groups. Therefore, the therapy for each patient group needs to be adjusted independently. "The many faces of fatigue" is the title of the symposium held to mark the retirement of Bleijenberg. Speakers from home and abroad discuss treatment of chronic fatigue in different groups of patients such as people with MS, COPD and heart disease.

Fortunately we have a political crisis in the Netherlands, so we hope there will be less coverage. Maybe that's why this was published today already, when the symposium around his retirement is upcoming friday.

In the Dutch magazine for Medical science there was also an article posted on a new definition of Chronic Fatique by this brilliant man. I will see if I can post a translation.

Does anyone know a translator for a text? I dont have the energy to do it myself and the article I have is not openly available on the internet, I only have it in Dutch on my Facebook page Esm de Groot. Maybe you can read a translation over there and post it here. I dont see how I can translate it, as Facebook knows I'm Dutch.

As a goodbye present, Bleijenberg gave us a Dutch guideline for CFS where his version of CBT/GET is the only option, medical examination is forbidden, and no care or social benefits will be provided if we don't accept this. All generously funded by the Dutch ministry of health.

However, different chronic fatigue states are not the same. The Donders found with the Nijmegen Research Centre Chronic Fatigue, that people with CFS have less gray matter in their brains than healthy people. After treatment with CBT, the volume of gray matter increases. On the other hand, in case of fatigue after cancer, there was no decrease in gray matter, and can be seen therefore, do not increase in gray matter after the treatment. This indicates that CFS is different biologically than cancer-related fatigue.

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The grey matter study was uncontrolled. The same change might potentially have been found in a control group (improvement isn't that uncommon esp. in the period after diagnosis). The change was only 12% of the gap to normal: http://brain.oxfordjournals.org/content/132/7/e119.long .

oceanblue's Google translation of Bleijenberg: However, different chronic fatigue states are not the same. The Donders found with the Nijmegen Research Centre Chronic Fatigue, that people with CFS have less gray matter in their brains than healthy people. After treatment with CBT, the volume of gray matter increases. On the other hand, in case of fatigue after cancer, there was no decrease in gray matter, and can be seen therefore, do not increase in gray matter after the treatment. This indicates that CFS is different biologically than cancer-related fatigue. Something similar can be seen at the level of the hormone cortisol in saliva. In CFS, this content is relatively low and it increases as the cognitive-behavioral starts better. In people who have had cancer, there is no difference in cortisol levels between fatigued and non-fatigued.

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Dolphin wrote: The grey matter study was uncontrolled. The same change might potentially have been found in a control group (improvement isn't that uncommon esp. in the period after diagnosis). The change was only 12% of the gap to normal: http://brain.oxfordjournals.org/content/132/7/e119.long .

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IIRC, the study showing cortisol increases after CBT was also uncontrolled. They could still argue that there are (small) differences between CFS vs healthy but not in fatigued vs non-fatigued cancer-related fatigue. However, I bet a search on PubMed would reveal studies which contradict that. There are also diagnostic issues about CFS that biopsychosocialists tend to ignore (they take a broad approach, don't care much for subtypes, endorse a paradoxical heterogeneity where everyone is unique but everyone must receive the same therapy).

Sometimes Google translation has quaint errors. At least it doesn't try to guess acronyms, someone reminded me recently that CBT also stands for "C*ck and Ball Torture" in the fetish world. Sounds like something right up Freud's ally, sorry moderators I couldn't help mentioning that, it is a funny coincidence!

... Bleijenberg: What amazes is that there is so little money is allocated to the national introduction of these effective therapies.

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His "amazement" suggests a disconnect with reality. Small subjective results in a minority of patients (questionnaire-taking behaviour, thanks Snow Leopard for the phrase), without objective decreases in disability, does not sound cost effective for governments. Perhaps they are also slow to act, or are also aware of the next door Belgian evaluation of the disappointing performance of CBT/GET in routine practice. Also, even if for the sake of argument we assumed the benefits are authentic without harm, I doubt that governments are generally concerned enough about ME/CFS patients to care about them subjectively and temporarily feeling a little better after $2000+ worth of therapy.

Phil Parker may have a similar "amazement" that the UK government aren't dumping truckloads of money on his lawn to solve the nation's problems.

Guido den Broeder wrote: As a goodbye present, Bleijenberg gave us a Dutch guideline for CFS where his version of CBT/GET is the only option, medical examination is forbidden, and no care or social benefits will be provided if we don't accept this. All generously funded by the Dutch ministry of health. http://www.mevereniging.nl/vernietigend-oordeel-over-cbo-richtlijn-cvs

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Scary stuff. And outsiders wonder why we "resist"? Would be ironic if Bleijenberg came down with a severe case of ME/CFS in his later retirement and became dismayed at the procedures he helped to set in motion. Well at first he might believe his own spin, until harsh reality sets in. That sort of happened to me when I was into the mind-body biopsychosocial stuff and believed it would help me. As their hypotheses become increasingly discredited, I want them to experience the same disillusionment I went through. Am I a bad person for that? Illness has not given me many "gifts", but sobering up from mind over body psychobabble was one of them.

SOC wrote: Sometimes, in order to move forward, we have to wait until the old men die (or retire). One down and how many to go?

LOL! They're probably terrified of me. As if I can do much more than wait -- for anything.

News Alert! Patients Threaten Kindly Doctors! Thousands upon thousands of ME/CFS patients wait threateningly for their hardworking, caring psycholgists to die or retire. "What next?" asks a psychologist specializing in ME/CFS, "First they won't listen to my advice, then they say mean things about me. Now they're waiting at me! Really! What next? Can I expect them to be looking at me funny? Will they make faces behind my back? This is becoming too much to bear. No professional should have to put up with this kind of abuse." What next, indeed! Soon these irrational patients will be asking for actual medical tests that could explain their symptoms. They are already demanding medical treatment appropriate for their symptoms. They have been refusing psychological treatment for medical conditions. Just how far will these renegades go?

Would be ironic if Bleijenberg came down with a severe case of ME/CFS in his later retirement and became dismayed at the procedures he helped to set in motion. Well at first he might believe his own spin, until harsh reality sets in.

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This actually happened to one of his assistants. Of course, the assistant lost his job, received no help from Bleijenberg whatsoever but found himself abandoned like the rest of us, and now shows up occasionally to testify against Gijs. The authorities ignore him, probably because he refused to take CBT/GET...

This actually happened to one of his assistants. Of course, the assistant lost his job, received no help from Bleijenberg whatsoever but found himself abandoned like the rest of us, and now shows up occasionally to testify against Gijs. The authorities ignore him, probably because he refused to take CBT/GET...

Sometimes Google translation has quaint errors. At least it doesn't try to guess acronyms, someone reminded me recently that CBT also stands for "C*ck and Ball Torture" in the fetish world. Sounds like something right up Freud's ally, sorry moderators I couldn't help mentioning that, it is a funny coincidence!

The grey matter study was uncontrolled. The same change might potentially have been found in a control group (improvement isn't that uncommon esp. in the period after diagnosis). The change was only 12% of the gap to normal: http://brain.oxfordjournals.org/content/132/7/e119.long .

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Sure: like most of the research on biological abnormaliites, it's pretty flaky (maybe even flakier than the psychological stuff, if that's possilbe). I highlighted that sentence "This indicates that CFS is different biologically than cancer-related fatigue" as I was surprised to see Bleijenberg making such a big deal about it. I know Simon Wessely has publicly stressed the biological abnormalites, to show what a genuinely reasonable guy he is, but I didn't think Bleijenberg bothered much with such niceties. It's odd he should give them such prominence in his swansong: 'The many Faces of Fatigue'. I just wondered if he's writing himself a small insurance policy in case the whole biopsychosocial edifice comes crashing down in the near future.